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• <br /> • <br /> -. Cant, <br /> if Safely and Buildings Division Dane 201 W.Weshlilgtun'Aye..P O:Bax 7162 Sanilery P'odlNumber(to be Slteiabye):' Masai,WI 537(IT-7162 <br /> t 13-2.N b'0059 <br /> StateTionsintiai Idtim er <br /> Sanitary Permit Application <br /> In 1u:cordmtec.with SP&38331k Wis.MO Code;atbmtssfml ottbis tent to the appmpoinpgoitemmentsl unit , <br /> is regnhd,prlorm Obtain IPA a'mn$ory ci ulL Note A'1plimt r.flnms arslate-mmed"POWTS;me soLmfnedi to Project Addiess:tirdt�aemEtait mailing'h Ess) <br /> IheEtepertinail orssfW mid Profe *rains. 2e®wad-ialbrmclon youpncvlde may beunod fartaondoy ` Q <br /> pmpotesioayssdo:e with dio.idveytal sjsa4(1rm1.9 task 1� \ <br /> Lincoln Road <br /> L Atm iiiiti fu-FpiifTon Please rilatAlflii onno iOn <br /> Propert.•Ownei•4Nmpe :. Pdcdd- ... <br /> Tom Buglass 0509-141-8500-1 <br /> Mp: •. .:iHa Address .. Ping4.Ey',Lociflon <br /> 5075 Lincoln 0 Govt. <br /> CEY,Slels Zip'Code P iVilinber NW t�,. NE 14 tendon 14, <br /> Oregon,WI 5 (eireleont) <br /> .11.TypeotBulldisg,(check all Oath_. Lot 9 T 5 rr a 9 E W <br /> Ia1or3t'amgyUwellhla- undiegor SatitllVidooMon)a <br /> 2 <br /> • y 35 Acre Metes&Bounds Parcel <br /> OPtpW(e2bttanaeial-Desi�rbetisp �- ❑'City ot. <br /> ❑sine. rated-Describe tine, .... .. CSM!Nouth ..... 0 YiUa`eor <br /> _.._... . <br /> M Toaa of Oregon <br /> lg.:,T7{reorPcrm)i: (Chpdtuufy=titi hasoh:ifdSA.CoaipkiMiiaeB'i€affpiteable) <br /> A' ki.New System eaxm$yslan .0 TrealmendHaldiag'1'onkReplacernan only ❑Other Modilloilbnto-Existing System(explain) <br /> B. ❑Ninth Renewal 0 l'ennit Revision 0 Omar ofP4mtmer !0*nob TmnikrtoNew ListPievioaspaap'lNiat ecandDate'Issoed <br /> BcfgicEspintion Owner. <br /> "IY.Tylicuf PO rS SysiithI,*dm onelidDevle :-Miceli of that apply) <br /> ®NoniPiessi hied la-Ground 0 Ptewarrzed to fi ound 0 Al-Grade 0 Moond>34 in otwilable soil 0 Moiod<24 in.orsndeble soil. <br /> 0Polding7pok O Other s)iapelsel Component(mplatn) 'ORrelrean:entIkvice(eaploin) ... . .. <br /> Y.DlspelsalirestmentArea lliformetion: <br /> Design Fioa(gpd) Desi OnSoil4nlleatiotRale(gpdal) Dispersal A?rn Rtgoired(sI)" • ixspessnl Area Proposed(al) System ideaarmii <br /> 300 0.4 750 756 95.9' <br /> VJ.Tolik-Info •Copnelty-i• Total Cor Mmtaraetmer A <br /> Gallons Gallons Units '= i;3 � .2 <br /> Aneroid& Ps&tiap Tanks V A m.B ran E t] cr <br /> 344k«1latdi,Tack 700/550 1250 1 Crest x <br /> Dos*Ceaeber <br /> VILResponsibilityStatement-t,tits oadeesI sned,=Imo rospanptbUttycorbtstnUado aftkePO WtSshownoetheattoOkodplays. <br /> Plwnbeeshiniie(Pdnp P. s tptdara idPIMPRSNumb& Business Phone aa.Raber <br /> RoderT EUets/ 1 ;e' )-7 .2a2-b (/4" 6DS3'7S'-('0390,• <br /> Plttoitbeek Address(sued,aty.siate,Zlp Gods)e> .. <br /> K onoty/Dapartment tUseOnly // <br /> O Disapproved Pen7ii Fee jfu'o ls�saed Is93 � � <br /> ❑Owner Given Reason for Denial• .�/ [ /,O c <br /> IX.Conditions of Appravol/Ressoes for Disapprover <br /> Allseb to anmplelp plot for lite:yam end sabsaa to the Caaaly Gab'as paper Rol less than a la s 11 Indust*slm <br /> SBD-6398(R.I l/I 1) <br />